Optimizing Wellness and Student Success. The Umbrella Model

Optimizing Wellness and Student Success. 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The Umbrella Model Laurarose Dunn-O’Farrell, Emilie Ludeman, Gerald Kayingo, Cara Felter This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6709430/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Nov, 2025 Read the published version in BMC Medical Education → Version 1 posted 5 You are reading this latest preprint version Abstract Background Health professions students are facing increased impairment, adverse academic experiences, and impeded performance. Despite the well-documented burnout, suicide risk, and other sequelae posing unnecessary challenges for these students, and the health professions community at large, poor quality of life and undesirable outcomes persist. Evidence suggests predisposing factors could be addressed during the student’s training period as pre-healthcare workforce (HCWs) or the preclinical workforce (PCW). This scoping review evaluates gaps in the research literature including alignment of terminology, wellness practices, and implications for students as the future HCW. Based on the findings, we propose The Umbrella Model for sustainable student success, well-being, and investment in long-term resilience. Methods Authors utilized a JBI scoping review protocol and logic model to investigate the research query. Literature retrieval was led by the research librarian using keywords, Boolean operators, and database-specific terminology. Using a PICOS framework and PRISMA tools, studies were vetted through a phased eligibility screening process according to inclusion/exclusion criteria (PA students, wellness practices, occurred within the U.S., original research). Data extraction occurred systematically and involved categorization of findings based on study sections and constructs. Findings were mapped to the National Wellness Institute (NWI) competency-based models and the PA Core Competencies. Results A total of 447 studies were retrieved from searches conducted via database searching (n = 439) and handsearching (n = 8). After initial screening and full-text review, 25 studies met inclusion criteria. Terminology, wellness practices, and instrumentation varied across the health professions programs. Few studies were anchored in learner-centered theory or pedagogical frameworks. Efficacious practices were often siloed, and no studies addressed all the dimensions of wellness. Unanimous findings support the need for well-being to promote student success. Conclusions Unified terminology, definitions, and implementation of wellness practices are necessary to optimize person-centered success, promote work-life balance, and transform antiquated systems into ecosystems equipped for long-term sustainability. Health professions student success well-being wellness practices physician assistant/associate (PA) program healthcare workforce preclinical resilience longevity competency-based education quality improvement Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 INTRODUCTION Statement of the Problem Exhaustion and burnout for healthcare workers (HCWs) and clinical educators were significant across the United States surrounding the COVID-19 pandemic.( 1 – 3 ) Physician assistants (PAs) and other clinicians face compounded risks for burnout, suicide, and somatic comorbidities even to present day.( 2 , 4 ) Numerous ‘calls to action’ have been raised about work-life imbalances and concerns for the well-being of HCWs to provide effective care despite facing increased risks of burnout and suicide.(2,5,6) Interventions have varied in scale and approach in attempts to mitigate these debilitating sequelae with minimal result.( 7 – 9 ) Reevaluation of “clinician life” is warranted to accurately address unmet wellness needs, which implores strategic analysis across experiences and contexts prior to clinical practice. With seasoned and seemingly resilient HCWs struggling, earlier surveillance and identification of precipitating factors is indicated, such as during the educational experience.( 8 , 10 – 13 ) Issues of diminished well-being, work-life balance, and quality of life for PAs and students—the preclinical workforce (PCW)—are well documented.( 9 , 14 – 17 ) PA education practices can potentiate a range of well-being experiences for PCW learners, both positive and negative, including trauma. ( 9 , 18 – 20 ) These effects have longstanding implications beyond the academic phase. As of the past several years, the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) (5th ed.) required instruction for “personal wellness” (B2.20a-b).( 21 , 22 ) Presently, efforts to address this standard in reality appear to miss the critical opportunity for holistic development and resilience-building in new graduates.( 6 , 18 , 19 , 23 , 24 ) Given continued national data trends, the ARC-PA 6th edition standards newly defines student ‘mistreatment’ to characterize negative experiences that have been illustrated in the PA Education Association (PAEA) annual reports.( 20 – 22 , 25 , 91 , 96 , 97 ) The data demonstrate continued barriers that detract from learner engagement, overarching success, and sustainability. Although well-intentioned, siloed and misguided efforts do not address the deeper layer of humanistic fundamentals that impact student experiences. Success is not simply a function of resource provision. Instead, it must coincide with identifying and removing barriers. Otherwise, content-packed curricula and dwindling time for self-care begs the question: How has the educational community lost sight of learner needs, prioritizing quantity (e.g., curricular content, class sizes, exam scores) over quality practices (e.g., learner-centered vs “student-focused” programming, well-rounded performance), including longitudinal curricular threading? Certain disciplines in health professions education (HPE), including PA education, are modeled on competency-based education (CBE).( 26 , 27 ) “Success” hinges on student development, progression, and performance across knowledge, skills, attitudes, and behaviors toward competency.( 21 , 26 , 28 , 29 ) Over-emphasis on academic achievement( 30 ) and allocation of general resources that are not targeted to student-specific needs overlooks the potential of wellness to help students reach desired outcomes. However, the related PA education literature is scant. This study aims to identify these research gaps for PA health profession students and programs by evaluating the existing work characterizing wellness practices and recommend potential interventions. The authors have developed a model (Figs. 3 – 5 ) that could be feasibly implemented in health professions education programs, which will be explored in the Discussion. Defining Success and the Dimensions of Wellness A 2023 systematic review examined international wellness models and found, “379 unique domains that could be clustered into 70 groups under 14 themes.”( 31 ) Despite the well-established need for wellness, there is no unified terminology for operationalizing experiences and assessment measures.( 31 – 34 ) ‘Wellness’ represents the transient state of an individual’s existence relative to different contexts or areas of their life at any given moment and requires small scale, routine upkeep to remain in a perceived space of homeostasis. Whereas ‘well-being’ represents a culminative humanistic experience( 31 , 32 ) comprised of many distinct yet overlapping facets, all influencing an individual’s ability to keep each “state of wellness” in balance. However, overall well-being through perceived “balance” can be disrupted through a shift of one or more facets of wellness. Further, resilience serves as the protective and rebounding force that enables an individual to maintain a relative state of balance and despite adverse experiences.( 35 ) Resilience longevity, like well-being, requires ongoing monitoring, investment, and maintenance. In 2023, the National Wellness Institute (NWI) established a competency-based model encompassing the multidimensional nature of wellness and defined wellness as “...functioning optimally within your current environment.”( 36 , 37 ) NWI uses wellness and well-being interchangeably to describe a holistic, or “whole person” experience, akin to quality of life and life satisfaction. Enveloping an individual’s experience of well-being are the NWI’s “Six Dimensions of Wellness:" Emotional, Intellectual, Occupational, Physical, Spiritual, and Social.( 37 , 38 ) Since experience and perspective vary at an individual level, these may be characterized as a range or continuum of well-being and wellness.( 37 – 39 ) To align terminology in this study, titles for 3 of the dimensions were expanded to the following: Emotional/Psychological, Intellectual/Mental, and Occupational/Academic.( 37 – 39 ) See Appendix 1 for dimension definitions. When wellness is optimized, individuals are empowered to pursue a state of well-being. For students in the PCW, optimizing wellness, and ultimately well-being, can bolster student success.( 2 , 4 , 8 – 10 ) Operationalizing definitions is crucial for effective communication and promoting shared understanding through an anchored framework.( 31 , 32 ) Through synthesis of literature and data, the authors developed a definition of ‘student success’ for use in this study: ( 7 , 20 – 22 , 31 , 32 , 34 , 40 ) The degree to which a student can equitably achieve desired objectives and learning outcomes within the direct purview of a program and educational institution. This must occur while: maintaining or enhancing baseline levels of overall well-being, and mitigating potential or actual disruption of progress that could otherwise diminish the effectiveness or quality of an educational experience, and ultimately, the journey of success. The NWI wellness dimensions are encapsulated by five multicultural domains (“D”), supported within the CBE framework( 26 , 27 ) and congruent with the requirements of medical learners:( 36 , 39 ) D1 = Authenticity and Self-Awareness, D2 = Whole-person and Systems Approaches, D3 = Inclusive and Responsive Practices, D4 = Communication and Connection, D5 = Legal and Ethical Principles.( 36 , 39 ) Human wellness is multidimensional and a global experience,( 7 , 23 , 41 ) therefore, applying wellness practices in PA curricula requires a multifaceted approach. The concept of “practices” can include various institutional and program interventions such as policy, procedure, curriculum, assessment, outcomes, infrastructure, program design, and faculty/staff related. PA programs must ensure practices are established, met, monitored, and addressed to foster quality improvement, meet accreditation standards, and transcend the educational experience with offerings that foster person and ecosystem resilience. ( 21 , 22 , 31 , 41 – 44 ) METHODS A scoping review was designed by 3 of the authors (LD, GK, CF) using evidence-based scoping review protocols from the Joanna Briggs Institute( 45 ) to guide the project query: “What terminology and wellness-based practices are being used in PA programs and what are the associated implications for student success?” Search Strategy Search strategies were developed in collaboration with a research librarian and included 2 overarching concepts: 1) PA students/programs, and 2) wellness/well-being. The following databases were searched in October 2024: MEDLINE (Ovid), ERIC (EBSCO), CINAHL (EBSCO) and Scopus (Elsevier) for studies published within the past 10 years. Study Selection, Literature Review, Screening, and Selection Eligibility criteria were structured with the PICOS framework. The review was managed, and screening decisions were captured, using Covidence software and are depicted in the PRISMA flowchart(46) (Fig. 1 ). Studies were required to meet the following inclusion criteria: 1) PA student participants, 2) wellness/well-being practices (interventions or exposures), 3) the study occurred in the United States (U.S.), and 4) was original research. Conversely, studies were excluded if they did not include PA students or if the study was non-U.S. based. Editorials and perspective articles were not included. References were imported to the Covidence software with duplicates removed. The remaining articles underwent eligibility screening by two of the authors (Fig. 1 ). Authors screened three studies at the start of each phase and compared decisions to ensure consensus and procedural accuracy. Conflicts were subsequently examined and mutually resolved. Data Extraction and Categorization Research logs were maintained in Microsoft Word (Version 2411, 18227.20162). A data extraction tool was created by two of the authors in Microsoft Excel (Version 2411, 18227.20162). The primary author conducted data extraction with support from the senior author. Studies were categorized based on inclusion criteria, keywords, aims, research problem framing, grounding or theoretical models utilized, methods, results, discussion/conclusions, and recommendations. Each wellness dimension was cross mapped with the educational competency domains set by the national PA organizations. “Well-being” was considered synonymous with the related overarching measures ‘quality of life’ and ‘life satisfaction.’ Directed content analysis( 47 ) was used to identify the presence and characteristics of: 1) terminology, 2) wellness practices, and 3) implications for student success as future HCWs. Constructs with directional tone were categorized based on the potential impact on wellness experiences (positive: enhances or improves, negative: diminishes or detracts). Each was subsequently matched to a best-fit dimension definition and then organized for secondary review and elimination of redundancy (Appendix 1). PA student experiences were examined across program progression, generally categorized as the didactic phase/year (DY), clinical phase/year (CY), or both. Findings pertinent to this study’s scope were summarized and cross-mapped according to the dimensions for analysis. RESULTS The screening and data extraction processes are depicted in Fig. 1 ; 447 references were imported for initial screening 141 duplicates were removed, 306 references underwent phase 1 (title and abstract) screening, and 13 conflicts were mutually resolved. Of the references excluded in phase 1, a common reason was that the acronym “PA” had been used to indicate “physical activity” instead of “physician assistant.” Forty studies were assessed in phase 2 screening (full text): 1 conflict was mutually resolved, and 25 studies met all inclusion criteria, all of which were published between 2019 and 2024 (Table 1). The included studies spanned 10 journals and included 20 unique first authors. Title Review Titles ranged between 7 to 23 words, with 48% of studies using 12 or fewer words.( 48 – 59 ) When comparing title words to the search strategy, the most frequently used terms in included: ‘Students’ (88%),( 48 – 51 , 53 – 69 ) ‘physician assistant’ (60%),( 49 – 51 , 53 , 55 – 61 , 64 , 65 , 68 , 69 ) health-profession or health science ‘student’ (16%),( 48 , 62 , 63 , 66 ) student type not specified (16%),( 70 , 71 , 52 , 54 ) and implied ‘PA student’ based on context (8%).( 67 , 72 ) Additional terminology included use of ‘program’ (16%),( 48 , 59 , 67 , 68 ) ‘experience’ (12%),( 55 , 65 , 69 ) and ‘institution’ (8%).( 55 , 58 ) Well-being’ or ‘wellness’ was found in 44% of study titles, ( 49 , 52 , 53 , 55 , 60 , 62 , 64 – 66 , 68 , 71 ) with 2/11 including both terms; ( 49 , 60 ) and 1 not counted in that total mentioned “whole person health.”( 70 ) Title constructs were mapped to the best-fit dimension and categorized (Appendix 1). Positive constructs were found in 92% of titles and negative constructs were present in 60% of titles (see Table 2). Contexts included curriculum design and/or delivery (60%),( 50 – 54 , 60 , 62 – 65 , 68 – 72 ) IPE events (16%),( 63 , 70 – 72 ) programmatic areas (12%),( 55 – 57 ) and assessment/outcomes (12%).( 53 , 54 , 61 ) Based on title alone, > 30% used positive terminology more than negative, and curricular design and/or delivery was examined at least 5 times more than other contexts. Beyond the Title Twenty-four percent of studies had keywords listed and coinciding with the top themes or concepts used within the specific publication. ( 48 , 55 , 58 , 62 – 64 ) Fewer than 28% noted frameworks for grounding including: learning theories,( 54 , 57 , 70 ) complementary and alternative medical (CAM) model, ( 71 ) wellness domains for resident training,( 65 ) perceived organizational justice framework, ( 55 ) and a model (“Ryff’s”)for psychological well-being.( 62 ) There were 9,628 PA student participants of diverse backgrounds and ages (Table 1). Three studies did not specify the participant breakdown for sample sizes - PA student,( 60 ) institution.( 57 , 66 ) The majority of study designs (68%) were multi-institutional. Programs’ sponsoring institutions ranged in location, size, sectors (public and private), matriculants, and hospital or medical school affiliation. Three studies (12%) also noted involvement of PA program faculty, staff, or mentors.( 60 , 61 , 70 ) Five studies (20%) incorporated interprofessional education (IPE) across 7 related health profession disciplines (massage therapy, medical, nursing, occupational therapy, pharmacy, physical therapy, speech-language pathology) ( 62 , 63 , 70 , 71 ) and 1 non-health profession discipline (theater).( 72 ) Over half (52%) of the studies examined the DY, 12% studied the CY, 28% studied both, and 2 did not specify (Table 1). Most commonly, wellness interventions occurred as in-person and synchronous learning with some instances of remote( 69 ) or asynchronous learning.( 51 ) Three research methods (quantitative, qualitative, mixed method) were used (Table 1). Twenty percent stated the research method( 54 , 55 , 62 , 69 , 70 ) explicitly and all provided robust descriptions of design. At least 35 differentinstruments were used for data collection. Surveys were the most common data collection method, with an average of 3 used per study. Studies mapped to multiple wellness dimensions (3–6 on average), with no studies addressing all 7 dimensions (Table 1). Three or more of the NWI multicultural competencies mapped to each of the 6 core and 2 cross-cutting PA competency domains.( 26 , 37 , 39 ) Pertinent findings were mapped to the 7 dimensions of wellness (Fig. 2 ). Subconstructs were categorized and listed in Appendix 1, including a total of 281 concepts (51% positive) (Table 2). Ninety-two percent included the specific terminology of “wellness” or “well-being” as part of the discussion relative to PA students and educational practices, with the remaining 8%( 63 , 72 ) addressing facets of “attitudes,” which could be collinear. Table 1. Scoping Synthesis and Findings [Additional file 1 – Table 1 would appear approximately here] Table 2. Directional Constructs and Wellness Dimension Mapping [Additional file 2 – Table 2 would appear approximately here] DISCUSSION To the authors’ knowledge, this is the first scoping review of wellness practices in PA education. Additionally, this study contributes to educational and clinical literature regarding evidence-based practice standards and quality improvement (QI) needs across programs, institutions, and within the health care system. Based on research and data synthesis across education, health professions, and leading health organizations, this is the first study observed by the authors to propose operational definitions and key distinctions for understanding and assessing “student success,” “wellness” versus “well-being,” and the application of a validated competency-based model, which aligns to CBE for the PCW and health professions at large. The critical analyses and recency of the nationwide studies included in this review support generalizability. A student’s educational experience propagates the future clinician, positively or negatively, toward a lifelong journey of learning and professional growth. These experiences are extensions of the knowledge, skills, attitudes, and behaviors instilled, shaped, and cultivated in a program. Related to wellness, an urgent review is warranted by the PA profession to explore: 1) terminology, 2) wellness practices, and 3) implications for student success as future providers. Terminology Heterogeneous terminology across studies, absence of author-supplied keywords, and directionality of construct tones complicated data synthesis. While this heterogeneity is not limited to PA literature, not speaking the same language proves challenging all the same. This challenge demonstrates the need to unify definitions, delineate wellness practice standards, and align the institutions with strategic systems-thinking( 74 ) to communicate efficiently and effectively. Language use, intentionality, contexts, and message reception are foundational principles of communication and professional practice. Interpersonal communication is among the core competency domains for the PA profession, including PA leaders.( 21 , 22 , 26 – 29 , 75 ) Comparison between the titles and the body of the studies revealed differing 1) directional terminology, and 2) dimensions (Fig. 2 ), which implies that some wellness dimensions receive more exploration (EP, IM) while others were rarely mentioned or directly assessed (Ph, Soc, Sp). Terminology in the titles did not consistently reflect what was examined in the body of the study, which limits recognition of the problems facing students today. Further, inconsistent terminology delays implementation of efficient and effective practices. The pool of terminology used across the literature demonstrates almost equal representation of positive (50.89%) and negative terms (49.11%) when investigating well-being. Positive subconstructs were most prevalent for 3 wellness dimensions (EP, IM, and OA) while negative subconstructs included the same 3 with 1 addition (Ph). Despite relative proportionality between positive/negative terminology, it appears that other crucial dimensions are not receiving equal attention in the literature: Ph, Sp, Soc, and OWB. These research gaps may suggest that approaches to student wellness and success have been too narrow, akin to treating sequalae and mistaking them as underlying causes. Based on the high degree of mapping alignment and nesting of terminology with the NWI competency-based model of wellness for HCWs, PA education competencies, and accreditation requirements, the authors posit that the model has high utility, feasibility, and cost-effectiveness for its integration into new and existing programs. Longitudinal threading is ideal, such as embedding wellness principles into program philosophy, pedagogical and assessment strategies, and operations (e.g., policies and procedures, faculty/staff development). Adoption and mindful implementation can cultivate tides for change and wellness, empowering students and others to “…function optimally within [their] current environment.”( 37 , 39 ) Wellness Practices While practice-based standards and competencies are often attributed to direct care clinicians, they have perhaps been under-acknowledged in PA programs. That is, the utility of validated frameworks “anchor” expectations and rationale, which inform varying levels of program operations, including as related to curricula, clinical educators, and student success. However, the inclusion of evidence-based models, including learning theory, pedagogical strategy, etc., was minimal in the studies examined herein. Curricular innovations for wellness practice instruction may have been statistically significant although their implementation was not threaded into the program or did not address whole-person wellness needs. Findings across the studies demonstrated positive and negative experiences impacting student perception, well-being, and subsequently outcomes. Studies most often examined wellness practices by “adding” to existing structures and schedules,( 76 ) indicating that changes are content driven with likely siloing, rather than threaded into the overall program philosophy and framework. Adding onto existing infrastructure rather than strategically removing or refining practices may predicate endless content cramming and haphazard approaches, requiring even more reason for theoretical grounding. Without purposeful actions, PA programs risk diminishing return on student investment. Siloing of wellness-focused educational content as seen in the included studies could impede the acquisition or future transfer of wellness practice knowledge, skills, attitudes, or behaviors beyond the classroom and into the clinical setting. For instance, literature frequently summates multi-faceted concepts, such as “burnout” – comprised of 3 subconstructs: emotional exhaustion, cynicism/depersonalization, reduced self-efficacy — into one primary term. Respectively, use of a primary term without acknowledgement of its subconstructs, and vice versa, may artificially appear singular. Further, terminology used during interpersonal exchanges (verbal and written) can serve to clarify how populations perceive, understand, identify, and label humanistic experiences in the future. Having robust and accurate characterization of these experiences mitigates the potential for inadvertent oversimplification and consequently, the risk of under-delivering necessary supports to enhance fundamental balance and well-being in academia and clinical practice settings. Consistently, studies demonstrated efficacy of wellness-based curricular innovations such as debriefing, decentering, and mindfulness techniques.( 49 , 50 , 52 , 53 , 62 – 64 ) Practice strategies that demonstrated mutual respect and consideration for students’ time as a valuable resource were well-received and validated the importance of meeting students’ wellness needs (e.g., time to attend medical appointments).( 54 , 55 , 61 , 65 , 68 – 70 ) Additionally, fostering program and educational cultures that are predictable yet not rigid, was highly regarded when implemented with appropriate scaffolding, reasonable boundaries, and realistic expectations.( 54 , 55 , 65 , 67 , 69 ) PA programs and institutions could build on the above noted successes when designing and delivering wellness curricula. Implications for Student Success as Future Providers Despite varied definitions and approaches to assess and foster student success, the undeniable and dominating mandate remains—advocating the return to the fundamentals of humanism, including into PA education. Prioritizing the needs of a person, as a human first, stands to generate inherent value-adds during the time-bound journey with a “student” persona. Addressing these concerns can improve variables critical to student success. The constructs synthesized from this review (Appendix 1) are not simply abstract concepts. Instead, each can contribute to a student’s experience – positive or negative, functioning as “protective” or “risk” factors to mediate outcomes of both success and toward well-being.( 35 ) Accreditation standards and PA competencies necessitate instruction for health promotion – prevention, screening, and maintenance,( 21 , 22 , 27 ) yet educational practices inadequately address the intangible, or “non-somatic” facets of negative student experiences and overarching unmet wellness needs, as individuals and as a collective.( 8 , 15 , 20 , 40 , 92 ) The U.S. approach to health and wellness is characteristic of a disease-driven system with emphasis on symptom management rather than preventive services. However, in the authors’ opinion, this traditional practice of clinical medicine has been long overdue for modernization and transformation. Where institutions have experienced unsynchronized systemic changes over years of scientific and technological expansion, embedding wellness frameworks, such as by NWI, can additionally inform evidence-based practice and education with practice approaches via positive psychology.( 23 ) Intentional approaches to frame verbal and written language shapes experiences that may create meaningful, positive change, or fuel negative neurobiological pathways.( 18 , 19 , 19 , 23 ) Collectively, such exchanges are micro-opportunities toward evidence-based healing practices such as cognitive restructuring. Healthier exposures and outlooks minimize the potential for unnecessary negativity that may otherwise diminish the quality of an experience and therefore, success toward actualization. Based on the research findings, individual’s perception of well-being is catalyzed by: 1) ability to compensate for or cope with dysregulation, 2) the type, frequency, and proportion of wellness dimensions affected by disruptions, and 3) the degree of influences contributing to meaningful increases/decreases in wellness. Therefore, burnout and other negative outcomes pose as an antithesis of health, well-being, or wellness, PA education could build on positive psychology principles to move from health promotion to health protection for students as future HCWs. The answer to the health burden of students cannot be addressed solely by adding to existing packed schedules( 92 , 96 , 97 ). The perpetuated zeitgeist of the past to “try harder” in the face of crippling HCW and PCW impairment across the U.S. is unacceptable and frankly, dangerous. Core to the physician assistant (PA) ethical duty( 77 ) is the charge to advocate as a systems-citizen( 44 ) and leader( 74 ) within the health care ecosystem, including the workplace, education, and research.( 26 , 75 , 78 ) As these issues continue to go unaddressed, the U.S.’s population health burdens of morbidity and mortality increase while the supply of competent and resilient new graduates poised to thrive long-term as HCWs dwindles. The nationwide HCW pulse is thready and in dire need of a wellness transfusion.( 3 , 15 , 23 , 24 , 79 ) Meanwhile, the hyper-fixation on student performance related to board exam outcomes or attrition is an oversimplification of “success” and inadequately characterizes the underlying problems faced by students. As the research findings support, the educational launchpad can serve as an environment to role model healthful practices in academia and strengthen trainees’ ability to transfer care skills across settings and above all, use them for self-care. Otherwise, educators may unintentionally assume a parentified role with students, leading to interpersonal shifts such as maladaptive “unprofessional behavior.” Meanwhile, implicit messaging of “do as I say and not as I do” in the educational environment is not congruent with learner-centered wellness practices. The barren landscape of emotional intelligence and such dynamics fuels unconscious incompetence, and the prevalence of negative student experiences across PA education speaks volumes to the illusory learner-centered environment. What is developed, including through educator modeling during this precious time, is critical.( 17 , 80 ) Much of PA education focuses on QI practices through self-assessment cycles, benchmark transparency, and practice approaches based on data and trend monitoring.( 21 ) It is possible that conceptualizing such benchmarks could unknowingly create the perception of a false dichotomy; that the threshold is either met or not met, each resulting in various action steps—often disciplinary in nature—and with outcomes negatively impacting students.( 55 ) The outcome does not negate what still occurs and is contributory behind the scenes. The articles reviewed indicate that optimization cannot occur proficiently without a scaffolded, longitudinal design to appropriately map the learner’s experience from matriculation through to HCW success. Increasing a learner’s potentiation must be propagated with supports whilst impediments are dismantled with through trauma-informed approaches.( 18 , 19 , 81 ) These needs were echoed diffusely across the diverse literature conclusions. The Institute for Healthcare Improvement’s (IHI) quintuple aim framework( 82 ) is worthy of inclusion in longitudinal program or curricular mapping for the PCW. Just as an injury leads to sequelae, prolonged systemic misalignment impedes efforts toward optimal health.( 6 , 9 , 34 , 42 , 74 , 83 , 84 ) Educational systems have been short-sighted by not considering students’ success as future healthcare practitioners’ success to promote healthful living and care for both patients, and themselves.( 6 , 8 , 19 , 90 ) Success is not limited to a board exam and is not a check-box to meet a quota or compliance visit. Reducing the burden of adverse experiences for PA students is possible – program training, empowering learner voice, fostering emotional intelligence growth, and redesigning schedules to reduce content quantity over quality, to name some strategies aligning with Table 1 practice data. What is success if not living purposefully, finding meaning and value across various areas of life, and having the tools to identify imbalance or restore equilibrium to the best of one’s ability for self and the community? The Umbrella Model: An Ecosystem of Student Success and Well-being Given the above critical appraisal of the literature and definition of student success, the authors introduce The Umbrella Model for student success and well-being. This model is intended to reframe our collective understanding and recommend practices to optimize student success across the educational ecosystem (Fig. 3 ). There are numerous forces contributing to the ‘balance’ of an educational ecosystem. These forces may be conceptualized as “success influencers.” Each equal and opposing force has the potential to change (or shape) a student’s experience in an instant, cumulatively, or both. These “influencers” are ever-occurring and in-motion, enhancing or diminishing the quality of an educational experience, and poise students closer to or farther from the desired outcomes. How a student is supported through their well-being and equipped to meet the milestone markers of success are guided by the program leadership practices, curriculum, and personnel. Although certain influencers can be forecasted and either prevented or mitigated, exposure to various elements is inevitable and at times unpredictable. However, the goal is not to simply provide an absolute shield for students to absolve or avoid exposure to diminishers; it is instead to scaffold, resource, and equitably support their path to enhance likelihoods of a productive and successful journey onward. It is within the purview of the educational ecosystem to maintain a clear and spacious pathway to prepare, develop, and equip learners to weather the challenges of future clinical practice. There are differing methods used to progress students’ knowledge, skills, attitudes/behaviors from a ‘novice’ PCW to a ‘competent’ HCW contributor. Although the pathway may vary, the overarching goal of the educational experience is transferable across health professions. The centralized shelter and protection afforded along this path is integral to the ecosystem infrastructure of educational experiences to come. Prior to a student leaving the program's protective covering at graduation, the program confers full “entrustment” to appropriately deploy and wield their own “umbrella” into the variable weather of future clinical practice and community betterment. Certain dimensions may, in essence, be larger than other dimensions for a given student. The dimensions - shown as rectangular boxes - have a similar although differing capacity in comparison to one another. These varied capacities represent the relative “size” of an individual’s need(s). How an individual, or student, carries the “weight” is determined by what is or isn’t contributing to meeting their “needs capacity.” Colloquially, this is reminiscent of the adage query: “what do you need to fill your cup?” Or rather, what are the needs of a student (or individual) and how can they best be met to enhance their resilience longevity toward continued successes and overall well-being? The distribution of each dimension on the scale will differ according to a student’s background, the social drivers, and the pathway maintained by a program’s self-assessment processes. How an educational program prepares, develops, and equips learners for success influencers has the potential to enhance or diminish the quality and value of the educational experience. Further, these success influencers and the roles within this educational ecosystem, are drivers (Fig. 5 ). Proactive forecasting, intentional efforts, and careful weaving of a longitudinal thread through program practices and organizational culture is vital. Alternatively, unmet needs of these dimensions perpetuate segmented (or siloed) approaches of imbalance and lead to the deterioration of the synergistic forces within the ecosystem. A state of balance is reflective of reality. As humans, there is always a need for replenishment and experiences in life will not be perfect. However, those experiences serve as refinement for growth, expertise, and wisdom. As long as balance is prioritized for students’ overall well-being, then successes, no matter the size, are inevitable. Limitations Data extraction and analysis proved challenging for several reasons including variable terminology, title brevity, descriptive inconsistencies, and sparse presence of keywords.( 43 ) Subconstruct terminology (e.g., burnout) was often used in the title with fewer than half of the studies including the overarching concept of well-being, limiting examination of the primary focus—wellness or well-being. Analysis was limited by the available data, with incomplete or omitted information denoted in Table 1. Recommendation for Future Works The authors identified a need for unified terminology related to wellness and student success; such work would benefit researchers and students alike. Investigation into the Ph, Sp, Soc, and OWB dimensions is lacking; thus, research focused on these dimensions would provide a more holistic understanding for researchers and education leadership. Finally, implementation and investigation of threaded curricula integrating wellness practices, trauma-informed pedagogy, and learning theory is a much-needed next step. Conclusion The need to unite wellness philosophy, definitions, and approaches to wellness practices is evidenced across this article’s findings and other prominent research in the health care community. Neglecting to implement wellness practices despite the overwhelming body of research conclusions that we don’t need to just try harder, we need to collectively shift the modus operandi of leadership and programs to foster longitudinal person-centered success. It is possible to employ systems-thinking( 74 ) though joint willingness to part with the comfortable practices of today and integrate the growth-mindset of future is not without its challenges. Across the U.S., the “needs assessment” has been performed and the research findings are sobering. Sustainability efforts to course-correct from preventable and unnecessary burdens of morbidity and mortality being faced by students and health professions are possible with coordinated efforts like the ones described in the umbrella model.( 2 , 3 , 7 , 17 , 20 , 80 , 85 , 86 ) Continuance of willful ignorance otherwise incites doubt for professional and ethical actions. It is time that PA education answers the call for action. Institutions nationally require imminent practice review and alignment, as the future of population well-being depends on it. Abbreviations ARC-PA - Accreditation Review Commission on Education for the Physician Assistant CBE - Competency-based Education HCW - Healthcare Workforce HPE - Health professions education PA - Physician Assistant/Associate PAEA - PA Education Association PCW - Preclinical Workforce QI - Quality Improvement Declarations Ethics approval and consent to participate Not applicable. Clinical trial number Not applicable. Consent for publication Not applicable. Availability of data and materials The dataset supporting the conclusions of this article is included within the article and its additional file(s). Competing interests The authors declare they have no competing interests. Funding The authors declare no funding sources. Author contributions LD collected, analyzed, and interpreted the study data; generated the dataset table and figures; and drafted and revised the manuscript iteratively. EL implemented the search strategy for literature retrieval and provided scholarly feedback. GK reviewed and provided scholarly feedback. CF was a major contributor to the study design, data interpretation, and manuscript revision. All authors read and approved the final manuscript. Acknowledgements These authors would like to thank the School of Graduate Studies of the University of Maryland-Baltimore (UMB) for their support in this research: Dr. Mary Jo Bondy, DHEd, PA-C, Program Director, Doctor of Medical Science (DMSc); and the PA Leadership & Learning Academy (PALLA). Authors’ information Not applicable. References Garvick S, Peacock B, Gillette C. COVID-19 and Physician Assistant Faculty Burnout: A Year into the Pandemic. J Physician Assist Educ. 2022 Jun;33(2):135–8. AAPA Joint Task Force. AAPA blueprint for addressing pa well-being and burnout [Internet]. 2020 [cited 2024 Oct 13]. Available from: https://www.aapa.org/news-central/2020/10/aapa-joint-task-force-on-burnout-offers-burnout-resources-on-website/ Dr. Lorna Breen Heroes’ Foundation. Dr. Lorna Breen Health Care Provider Protection Reauthorization Act [Internet]. 2020 [cited 2024 Sept 23]. Available from: https://drlornabreen.org/ Sullivan AG, Hoffman A, Slavin S. 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Burnout: A review of theory and measurement. IJERPH. 2022 Feb 4;19(3):1780. Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.docx Additional material File name: Additional file 1 File format: docx Title of data: Table 1: Scoping Synthesis and Findings Description of data: Findings from the studies reviewed Additionalfile2.docx Additional material File name: Additional file 2 File format: docx Title of data: Table 2: Directional Constructs and Wellness Dimension Mapping Description of data: Prevalence of constructs within the title and body of each study Appendix.docx Cite Share Download PDF Status: Published Journal Publication published 13 Nov, 2025 Read the published version in BMC Medical Education → Version 1 posted Reviewers agreed at journal 05 Jun, 2025 Reviewers invited by journal 03 Jun, 2025 Editor assigned by journal 28 May, 2025 Submission checks completed at journal 28 May, 2025 First submitted to journal 20 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6709430","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":466534725,"identity":"8e74d0c1-486b-4fe8-b5ae-0cc25b31f95f","order_by":0,"name":"Laurarose Dunn-O’Farrell","email":"data:image/png;base64,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","orcid":"","institution":"University of Maryland, Baltimore","correspondingAuthor":true,"prefix":"","firstName":"Laurarose","middleName":"","lastName":"Dunn-O’Farrell","suffix":""},{"id":466534726,"identity":"0e9f113f-3b31-4486-bdce-35ae187d28ae","order_by":1,"name":"Emilie Ludeman","email":"","orcid":"","institution":"University of Maryland, Baltimore","correspondingAuthor":false,"prefix":"","firstName":"Emilie","middleName":"","lastName":"Ludeman","suffix":""},{"id":466534727,"identity":"8ccd060a-86b8-4aaf-b64d-27e662fb1dd5","order_by":2,"name":"Gerald Kayingo","email":"","orcid":"","institution":"University of Maryland, Baltimore","correspondingAuthor":false,"prefix":"","firstName":"Gerald","middleName":"","lastName":"Kayingo","suffix":""},{"id":466534728,"identity":"82f2e988-3be5-4c0f-a785-c9ee02eb53b3","order_by":3,"name":"Cara Felter","email":"","orcid":"","institution":"University of Maryland, Baltimore","correspondingAuthor":false,"prefix":"","firstName":"Cara","middleName":"","lastName":"Felter","suffix":""}],"badges":[],"createdAt":"2025-05-20 15:53:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6709430/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6709430/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-08009-6","type":"published","date":"2025-11-14T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84026834,"identity":"cca7175d-1df2-4470-8002-e02f3aea8f65","added_by":"auto","created_at":"2025-06-06 00:30:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":373717,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA Flow Diagram: Screening Phases and Study Eligibility\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6709430/v1/21f42beaeeba70fee96c0fd6.png"},{"id":84026452,"identity":"c54e72ac-e728-4400-888d-0a6372a4576a","added_by":"auto","created_at":"2025-06-06 00:22:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":114728,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eWellness Findings: % Represented in the Literature\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003erepresents the seven (7) dimensions of wellness (x-axis) and the percentage (%) of mapped scoping review findings (y-axis) from Table 1. The definitions for each dimension (Appendix 1) were used to cross-map the studies (n = 25).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6709430/v1/9ccfbc5aa6336fab64a6d6ce.png"},{"id":84026459,"identity":"40b0baa6-ac1c-4bcc-b4b4-b65a4afb41d9","added_by":"auto","created_at":"2025-06-06 00:22:06","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1157721,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Umbrella Model\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Umbrella Model represents the dynamic influences spanning both the educational journey and lifelong continuum which underpin student success and well-being. When well-being is optimized within a community and for an individual, the journey of micro and macro successes imbue resilience longevity as a synergistic ecosystem.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6709430/v1/0c360570d5ed98f040ac41c6.png"},{"id":84026460,"identity":"307a8d8b-adad-4636-8943-a01b7a391e00","added_by":"auto","created_at":"2025-06-06 00:22:06","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":52361,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Scale of Well-being and Success\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis figure illustrates the overarching dynamic forces that can influence an individual’s perception or experience of overall well-being and therefore, “balance.” Data from Table 2 - ‘\u003cem\u003eWithin the Study’ - \u003c/em\u003eis transposed into this figure to showcase the imbalanced distribution of the wellness dimensions according to the research findings. This “snapshot” depicts the protective covering provided by an educational program through which a student will continue onward into clinical practice competently equipped with their own “umbrella.” The program provides the interwoven (or threaded) support for the student’s journey and is responsible for fostering an experience of quality and value to balance the inequities faced by students. Thus, the representation of the scale and the distribution of the dimensions are not static and may be shown conversely in a more horizontal position (i.e., 0 degrees) of equilibrium.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6709430/v1/02023b661f73c2fcdffc0276.png"},{"id":84026461,"identity":"66c097fd-ab7e-4b74-ad15-cb577c02f99a","added_by":"auto","created_at":"2025-06-06 00:22:07","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":350371,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDrivers and Influencers of the Educational Ecosystem\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe success influencers of the educational ecosystem align with QI diagramming to further illustrate the intertwined aim for student success and well-being. Ultimate student success cannot be achieved without the prerequisite of overall well-being needs being met (Figure 4).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6709430/v1/37f724009821564f3a8d3ab0.png"},{"id":95948966,"identity":"d79d18a4-cf2f-4519-a359-7cfefe06dedc","added_by":"auto","created_at":"2025-11-14 18:43:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3268912,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6709430/v1/9aca3ef6-a3f1-4128-b19a-5a6c8316fd95.pdf"},{"id":84026457,"identity":"b2cdc550-2e83-4e20-9073-a49c3f8b11db","added_by":"auto","created_at":"2025-06-06 00:22:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":58935,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFile name: Additional file 1\u003c/p\u003e\n\u003cp\u003eFile format: docx\u003c/p\u003e\n\u003cp\u003eTitle of data: Table 1: Scoping Synthesis and Findings\u003c/p\u003e\n\u003cp\u003eDescription of data: Findings from the studies reviewed\u003c/p\u003e","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6709430/v1/69090efa5ad76339aa1c4996.docx"},{"id":84026458,"identity":"2b12e331-97f7-4d47-9b95-b1506377c103","added_by":"auto","created_at":"2025-06-06 00:22:06","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":26193,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFile name: Additional file 2\u003c/p\u003e\n\u003cp\u003eFile format: docx\u003c/p\u003e\n\u003cp\u003eTitle of data: Table 2: Directional Constructs and Wellness Dimension Mapping\u003c/p\u003e\n\u003cp\u003eDescription of data: Prevalence of constructs within the title and body of each study\u003c/p\u003e","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6709430/v1/76342c564a37941aa2001e7a.docx"},{"id":84026456,"identity":"7bee1f6c-0b6d-4484-a67c-a1ddbd257a00","added_by":"auto","created_at":"2025-06-06 00:22:06","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":21838,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-6709430/v1/00d88d8ad9d0a3eb0df97014.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eOptimizing Wellness and Student Success. The Umbrella Model\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eStatement of the Problem\u003c/h2\u003e \u003cp\u003eExhaustion and burnout for healthcare workers (HCWs) and clinical educators were significant across the United States surrounding the COVID-19 pandemic.(\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Physician assistants (PAs) and other clinicians face compounded risks for burnout, suicide, and somatic comorbidities even to present day.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Numerous \u0026lsquo;calls to action\u0026rsquo; have been raised about work-life imbalances and concerns for the well-being of HCWs to provide effective care despite facing increased risks of burnout and suicide.(2,5,6) Interventions have varied in scale and approach in attempts to mitigate these debilitating sequelae with minimal result.(\u003cspan additionalcitationids=\"CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Reevaluation of \u0026ldquo;clinician life\u0026rdquo; is warranted to accurately address unmet wellness needs, which implores strategic analysis across experiences and contexts prior to clinical practice. With seasoned and seemingly resilient HCWs struggling, earlier surveillance and identification of precipitating factors is indicated, such as during the educational experience.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIssues of diminished well-being, work-life balance, and quality of life for PAs and students\u0026mdash;the preclinical workforce (PCW)\u0026mdash;are well documented.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e) PA education practices can potentiate a range of well-being experiences for PCW learners, both positive and negative, including trauma. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e) These effects have longstanding implications beyond the academic phase. As of the past several years, the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) (5th ed.) required instruction for \u0026ldquo;personal wellness\u0026rdquo; (B2.20a-b).(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e) Presently, efforts to address this standard in reality appear to miss the critical opportunity for holistic development and resilience-building in new graduates.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e24\u003c/span\u003e) Given continued national data trends, the ARC-PA 6th edition standards newly defines student \u0026lsquo;mistreatment\u0026rsquo; to characterize negative experiences that have been illustrated in the PA Education Association (PAEA) annual reports.(\u003cspan additionalcitationids=\"CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e91\u003c/span\u003e, \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e96\u003c/span\u003e, \u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e97\u003c/span\u003e) The data demonstrate continued barriers that detract from learner engagement, overarching success, and sustainability. Although well-intentioned, siloed and misguided efforts do not address the deeper layer of humanistic fundamentals that impact student experiences. Success is not simply a function of resource provision. Instead, it must coincide with identifying and removing barriers. Otherwise, content-packed curricula and dwindling time for self-care begs the question: How has the educational community lost sight of learner needs, prioritizing quantity (e.g., curricular content, class sizes, exam scores) over quality practices (e.g., learner-centered vs \u0026ldquo;student-focused\u0026rdquo; programming, well-rounded performance), including longitudinal curricular threading?\u003c/p\u003e \u003cp\u003eCertain disciplines in health professions education (HPE), including PA education, are modeled on competency-based education (CBE).(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e27\u003c/span\u003e) \u0026ldquo;Success\u0026rdquo; hinges on student development, progression, and performance across knowledge, skills, attitudes, and behaviors toward competency.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Over-emphasis on academic achievement(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e30\u003c/span\u003e) and allocation of general resources that are not targeted to student-specific needs overlooks the potential of wellness to help students reach desired outcomes. However, the related PA education literature is scant. This study aims to identify these research gaps for PA health profession students and programs by evaluating the existing work characterizing wellness practices and recommend potential interventions. The authors have developed a model (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) that could be feasibly implemented in health professions education programs, which will be explored in the Discussion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDefining Success and the Dimensions of Wellness\u003c/h2\u003e \u003cp\u003eA 2023 systematic review examined international wellness models and found, \u0026ldquo;379 unique domains that could be clustered into 70 groups under 14 themes.\u0026rdquo;(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e31\u003c/span\u003e) Despite the well-established need for wellness, there is no unified terminology for operationalizing experiences and assessment measures.(\u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR30\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e34\u003c/span\u003e) \u0026lsquo;Wellness\u0026rsquo; represents the transient state of an individual\u0026rsquo;s existence relative to different contexts or areas of their life at any given moment and requires small scale, routine upkeep to remain in a perceived space of homeostasis. Whereas \u0026lsquo;well-being\u0026rsquo; represents a culminative humanistic experience(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e32\u003c/span\u003e) comprised of many distinct yet overlapping facets, all influencing an individual\u0026rsquo;s ability to keep each \u0026ldquo;state of wellness\u0026rdquo; in balance. However, overall well-being through perceived \u0026ldquo;balance\u0026rdquo; can be disrupted through a shift of one or more facets of wellness. Further, resilience serves as the protective and rebounding force that enables an individual to maintain a relative state of balance and despite adverse experiences.(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Resilience longevity, like well-being, requires ongoing monitoring, investment, and maintenance.\u003c/p\u003e \u003cp\u003eIn 2023, the National Wellness Institute (NWI) established a competency-based model encompassing the multidimensional nature of wellness and defined wellness as \u0026ldquo;...functioning optimally within your current environment.\u0026rdquo;(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e37\u003c/span\u003e) NWI uses wellness and well-being interchangeably to describe a holistic, or \u0026ldquo;whole person\u0026rdquo; experience, akin to quality of life and life satisfaction. Enveloping an individual\u0026rsquo;s experience of well-being are the NWI\u0026rsquo;s \u0026ldquo;Six Dimensions of Wellness:\" Emotional, Intellectual, Occupational, Physical, Spiritual, and Social.(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e38\u003c/span\u003e) Since experience and perspective vary at an individual level, these may be characterized as a range or continuum of well-being and wellness.(\u003cspan additionalcitationids=\"CR38\" citationid=\"CR36\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e39\u003c/span\u003e) To align terminology in this study, titles for 3 of the dimensions were expanded to the following: Emotional/Psychological, Intellectual/Mental, and Occupational/Academic.(\u003cspan additionalcitationids=\"CR38\" citationid=\"CR36\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e39\u003c/span\u003e) See Appendix 1 for dimension definitions.\u003c/p\u003e \u003cp\u003eWhen wellness is optimized, individuals are empowered to pursue a state of well-being. For students in the PCW, optimizing wellness, and ultimately well-being, can bolster student success.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e10\u003c/span\u003e) Operationalizing definitions is crucial for effective communication and promoting shared understanding through an anchored framework.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e32\u003c/span\u003e) Through synthesis of literature and data, the authors developed a definition of \u0026lsquo;student success\u0026rsquo; for use in this study: (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e40\u003c/span\u003e)\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe degree to which a student can equitably achieve desired objectives and learning outcomes within the direct purview of a program and educational institution. This must occur while:\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003emaintaining or enhancing baseline levels of overall well-being, and\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003emitigating potential or actual disruption of progress that could otherwise diminish the effectiveness or quality of an educational experience, and ultimately, the journey of success.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe NWI wellness dimensions are encapsulated by five multicultural domains (\u0026ldquo;D\u0026rdquo;), supported within the CBE framework(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e27\u003c/span\u003e) and congruent with the requirements of medical learners:(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e39\u003c/span\u003e) D1\u0026thinsp;=\u0026thinsp;Authenticity and Self-Awareness, D2\u0026thinsp;=\u0026thinsp;Whole-person and Systems Approaches, D3\u0026thinsp;=\u0026thinsp;Inclusive and Responsive Practices, D4\u0026thinsp;=\u0026thinsp;Communication and Connection, D5\u0026thinsp;=\u0026thinsp;Legal and Ethical Principles.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e39\u003c/span\u003e) Human wellness is multidimensional and a global experience,(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e41\u003c/span\u003e) therefore, applying wellness practices in PA curricula requires a multifaceted approach. The concept of \u0026ldquo;practices\u0026rdquo; can include various institutional and program interventions such as policy, procedure, curriculum, assessment, outcomes, infrastructure, program design, and faculty/staff related. PA programs must ensure practices are established, met, monitored, and addressed to foster quality improvement, meet accreditation standards, and transcend the educational experience with offerings that foster person and ecosystem resilience. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan additionalcitationids=\"CR42 CR43\" citationid=\"CR40\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e44\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e"},{"header":"METHODS","content":"\u003cp\u003eA scoping review was designed by 3 of the authors (LD, GK, CF) using evidence-based scoping review protocols from the Joanna Briggs Institute(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e45\u003c/span\u003e) to guide the project query: \u0026ldquo;What terminology and wellness-based practices are being used in PA programs and what are the associated implications for student success?\u0026rdquo;\u003c/p\u003e\n\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eSearch strategies were developed in collaboration with a research librarian and included 2 overarching concepts: 1) PA students/programs, and 2) wellness/well-being. The following databases were searched in October 2024: MEDLINE (Ovid), ERIC (EBSCO), CINAHL (EBSCO) and Scopus (Elsevier) for studies published within the past 10 years.\u003c/p\u003e\n\u003ch3\u003eStudy Selection, Literature Review, Screening, and Selection\u003c/h3\u003e\n\u003cp\u003eEligibility criteria were structured with the PICOS framework. The review was managed, and screening decisions were captured, using Covidence software and are depicted in the PRISMA flowchart(46) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Studies were required to meet the following inclusion criteria: 1) PA student participants, 2) wellness/well-being practices (interventions or exposures), 3) the study occurred in the United States (U.S.), and 4) was original research. Conversely, studies were excluded if they did not include PA students or if the study was non-U.S. based. Editorials and perspective articles were not included.\u003c/p\u003e \u003cp\u003eReferences were imported to the Covidence software with duplicates removed. The remaining articles underwent eligibility screening by two of the authors (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Authors screened three studies at the start of each phase and compared decisions to ensure consensus and procedural accuracy. Conflicts were subsequently examined and mutually resolved.\u003c/p\u003e\n\u003ch3\u003eData Extraction and Categorization\u003c/h3\u003e\n\u003cp\u003eResearch logs were maintained in Microsoft Word (Version 2411, 18227.20162). A data extraction tool was created by two of the authors in Microsoft Excel (Version 2411, 18227.20162). The primary author conducted data extraction with support from the senior author. Studies were categorized based on inclusion criteria, keywords, aims, research problem framing, grounding or theoretical models utilized, methods, results, discussion/conclusions, and recommendations. Each wellness dimension was cross mapped with the educational competency domains set by the national PA organizations.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Well-being\u0026rdquo; was considered synonymous with the related overarching measures \u0026lsquo;quality of life\u0026rsquo; and \u0026lsquo;life satisfaction.\u0026rsquo; Directed content analysis(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e47\u003c/span\u003e) was used to identify the presence and characteristics of: 1) terminology, 2) wellness practices, and 3) implications for student success as future HCWs. Constructs with directional tone were categorized based on the potential impact on wellness experiences (positive: enhances or improves, negative: diminishes or detracts). Each was subsequently matched to a best-fit dimension definition and then organized for secondary review and elimination of redundancy (Appendix 1). PA student experiences were examined across program progression, generally categorized as the didactic phase/year (DY), clinical phase/year (CY), or both. Findings pertinent to this study\u0026rsquo;s scope were summarized and cross-mapped according to the dimensions for analysis.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe screening and data extraction processes are depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; 447 references were imported for initial screening 141 duplicates were removed, 306 references underwent phase 1 (title and abstract) screening, and 13 conflicts were mutually resolved. Of the references excluded in phase 1, a common reason was that the acronym \u0026ldquo;PA\u0026rdquo; had been used to indicate \u0026ldquo;physical activity\u0026rdquo; instead of \u0026ldquo;physician assistant.\u0026rdquo; Forty studies were assessed in phase 2 screening (full text): 1 conflict was mutually resolved, and 25 studies met all inclusion criteria, all of which were published between 2019 and 2024 (Table\u0026nbsp;1). The included studies spanned 10 journals and included 20 unique first authors.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eTitle Review\u003c/h3\u003e\n\u003cp\u003eTitles ranged between 7 to 23 words, with 48% of studies using 12 or fewer words.(\u003cspan additionalcitationids=\"CR49 CR50 CR51 CR52 CR53 CR54 CR55 CR56 CR57 CR58\" citationid=\"CR46\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e59\u003c/span\u003e) When comparing title words to the search strategy, the most frequently used terms in included: \u0026lsquo;Students\u0026rsquo; (88%),(\u003cspan additionalcitationids=\"CR49 CR50\" citationid=\"CR46\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan additionalcitationids=\"CR54 CR55 CR56 CR57 CR58 CR59 CR60 CR61 CR62 CR63 CR64 CR65 CR66 CR67 CR68\" citationid=\"CR51\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e69\u003c/span\u003e) \u0026lsquo;physician assistant\u0026rsquo; (60%),(\u003cspan additionalcitationids=\"CR50\" citationid=\"CR47\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan additionalcitationids=\"CR56 CR57 CR58 CR59 CR60\" citationid=\"CR53\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e69\u003c/span\u003e) health-profession or health science \u0026lsquo;student\u0026rsquo; (16%),(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e66\u003c/span\u003e) student type not specified (16%),(\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e54\u003c/span\u003e) and implied \u0026lsquo;PA student\u0026rsquo; based on context (8%).(\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e72\u003c/span\u003e) Additional terminology included use of \u0026lsquo;program\u0026rsquo; (16%),(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e68\u003c/span\u003e) \u0026lsquo;experience\u0026rsquo; (12%),(\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e69\u003c/span\u003e) and \u0026lsquo;institution\u0026rsquo; (8%).(\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e58\u003c/span\u003e) Well-being\u0026rsquo; or \u0026lsquo;wellness\u0026rsquo; was found in 44% of study titles, (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan additionalcitationids=\"CR65\" citationid=\"CR62\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e71\u003c/span\u003e) with 2/11 including both terms; (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e60\u003c/span\u003e) and 1 not counted in that total mentioned \u0026ldquo;whole person health.\u0026rdquo;(\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e70\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTitle constructs were mapped to the best-fit dimension and categorized (Appendix 1). Positive constructs were found in 92% of titles and negative constructs were present in 60% of titles (see Table\u0026nbsp;2). Contexts included curriculum design and/or delivery (60%),(\u003cspan additionalcitationids=\"CR51 CR52 CR53\" citationid=\"CR48\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan additionalcitationids=\"CR63 CR64\" citationid=\"CR60\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan additionalcitationids=\"CR69 CR70 CR71\" citationid=\"CR66\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e72\u003c/span\u003e) IPE events (16%),(\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan additionalcitationids=\"CR71\" citationid=\"CR68\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e72\u003c/span\u003e) programmatic areas (12%),(\u003cspan additionalcitationids=\"CR56\" citationid=\"CR53\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e57\u003c/span\u003e) and assessment/outcomes (12%).(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e61\u003c/span\u003e) Based on title alone, \u0026gt; 30% used positive terminology more than negative, and curricular design and/or delivery was examined at least 5 times more than other contexts.\u003c/p\u003e\n\u003ch3\u003eBeyond the Title\u003c/h3\u003e\n\u003cp\u003eTwenty-four percent of studies had keywords listed and coinciding with the top themes or concepts used within the specific publication. (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan additionalcitationids=\"CR63\" citationid=\"CR60\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e64\u003c/span\u003e) Fewer than 28% noted frameworks for grounding including: learning theories,(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e70\u003c/span\u003e) complementary and alternative medical (CAM) model, (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e71\u003c/span\u003e) wellness domains for resident training,(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e65\u003c/span\u003e) perceived organizational justice framework, (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e55\u003c/span\u003e) and a model (\u0026ldquo;Ryff\u0026rsquo;s\u0026rdquo;)for psychological well-being.(\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e62\u003c/span\u003e) There were 9,628 PA student participants of diverse backgrounds and ages (Table\u0026nbsp;1). Three studies did not specify the participant breakdown for sample sizes - PA student,(\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e60\u003c/span\u003e) institution.(\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e66\u003c/span\u003e) The majority of study designs (68%) were multi-institutional. Programs\u0026rsquo; sponsoring institutions ranged in location, size, sectors (public and private), matriculants, and hospital or medical school affiliation. Three studies (12%) also noted involvement of PA program faculty, staff, or mentors.(\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e70\u003c/span\u003e) Five studies (20%) incorporated interprofessional education (IPE) across 7 related health profession disciplines (massage therapy, medical, nursing, occupational therapy, pharmacy, physical therapy, speech-language pathology) (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e71\u003c/span\u003e) and 1 non-health profession discipline (theater).(\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e72\u003c/span\u003e) Over half (52%) of the studies examined the DY, 12% studied the CY, 28% studied both, and 2 did not specify (Table\u0026nbsp;1). Most commonly, wellness interventions occurred as in-person and synchronous learning with some instances of remote(\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e69\u003c/span\u003e) or asynchronous learning.(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e51\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThree research methods (quantitative, qualitative, mixed method) were used (Table\u0026nbsp;1). Twenty percent stated the research method(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e70\u003c/span\u003e) explicitly and all provided robust descriptions of design. At least 35 differentinstruments were used for data collection. Surveys were the most common data collection method, with an average of 3 used per study.\u003c/p\u003e \u003cp\u003eStudies mapped to multiple wellness dimensions (3\u0026ndash;6 on average), with no studies addressing all 7 dimensions (Table\u0026nbsp;1). Three or more of the NWI multicultural competencies mapped to each of the 6 core and 2 cross-cutting PA competency domains.(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e39\u003c/span\u003e) Pertinent findings were mapped to the 7 dimensions of wellness (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Subconstructs were categorized and listed in Appendix 1, including a total of 281 concepts (51% positive) (Table\u0026nbsp;2). Ninety-two percent included the specific terminology of \u0026ldquo;wellness\u0026rdquo; or \u0026ldquo;well-being\u0026rdquo; as part of the discussion relative to PA students and educational practices, with the remaining 8%(\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e72\u003c/span\u003e) addressing facets of \u0026ldquo;attitudes,\u0026rdquo; which could be collinear.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;1. Scoping Synthesis and Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e[Additional file 1 \u0026ndash; Table\u0026nbsp;1 would appear approximately here]\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"7\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;2. Directional Constructs and Wellness Dimension Mapping\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e[Additional file 2 \u0026ndash; Table\u0026nbsp;2 would appear approximately here]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"},{"header":"DISCUSSION","content":"\u003cp\u003eTo the authors\u0026rsquo; knowledge, this is the first scoping review of wellness practices in PA education. Additionally, this study contributes to educational and clinical literature regarding evidence-based practice standards and quality improvement (QI) needs across programs, institutions, and within the health care system. Based on research and data synthesis across education, health professions, and leading health organizations, this is the first study observed by the authors to propose operational definitions and key distinctions for understanding and assessing \u0026ldquo;student success,\u0026rdquo; \u0026ldquo;wellness\u0026rdquo; versus \u0026ldquo;well-being,\u0026rdquo; and the application of a validated competency-based model, which aligns to CBE for the PCW and health professions at large. The critical analyses and recency of the nationwide studies included in this review support generalizability.\u003c/p\u003e \u003cp\u003eA student\u0026rsquo;s educational experience propagates the future clinician, positively or negatively, toward a lifelong journey of learning and professional growth. These experiences are extensions of the knowledge, skills, attitudes, and behaviors instilled, shaped, and cultivated in a program. Related to wellness, an urgent review is warranted by the PA profession to explore: 1) terminology, 2) wellness practices, and 3) implications for student success as future providers.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTerminology\u003c/h2\u003e \u003cp\u003eHeterogeneous terminology across studies, absence of author-supplied keywords, and directionality of construct tones complicated data synthesis. While this heterogeneity is not limited to PA literature, not speaking the same language proves challenging all the same. This challenge demonstrates the need to unify definitions, delineate wellness practice standards, and align the institutions with strategic systems-thinking(\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e74\u003c/span\u003e) to communicate efficiently and effectively. Language use, intentionality, contexts, and message reception are foundational principles of communication and professional practice. Interpersonal communication is among the core competency domains for the PA profession, including PA leaders.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e75\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eComparison between the titles and the body of the studies revealed differing 1) directional terminology, and 2) dimensions (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), which implies that some wellness dimensions receive more exploration (EP, IM) while others were rarely mentioned or directly assessed (Ph, Soc, Sp). Terminology in the titles did not consistently reflect what was examined in the body of the study, which limits recognition of the problems facing students today. Further, inconsistent terminology delays implementation of efficient and effective practices. The pool of terminology used across the literature demonstrates almost equal representation of positive (50.89%) and negative terms (49.11%) when investigating well-being. Positive subconstructs were most prevalent for 3 wellness dimensions (EP, IM, and OA) while negative subconstructs included the same 3 with 1 addition (Ph). Despite relative proportionality between positive/negative terminology, it appears that other crucial dimensions are not receiving equal attention in the literature: Ph, Sp, Soc, and OWB. These research gaps may suggest that approaches to student wellness and success have been too narrow, akin to treating sequalae and mistaking them as underlying causes.\u003c/p\u003e \u003cp\u003eBased on the high degree of mapping alignment and nesting of terminology with the NWI competency-based model of wellness for HCWs, PA education competencies, and accreditation requirements, the authors posit that the model has high utility, feasibility, and cost-effectiveness for its integration into new and existing programs. Longitudinal threading is ideal, such as embedding wellness principles into program philosophy, pedagogical and assessment strategies, and operations (e.g., policies and procedures, faculty/staff development). Adoption and mindful implementation can cultivate tides for change and wellness, empowering students and others to \u0026ldquo;\u0026hellip;function optimally within [their] current environment.\u0026rdquo;(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eWellness Practices\u003c/h2\u003e \u003cp\u003eWhile practice-based standards and competencies are often attributed to direct care clinicians, they have perhaps been under-acknowledged in PA programs. That is, the utility of validated frameworks \u0026ldquo;anchor\u0026rdquo; expectations and rationale, which inform varying levels of program operations, including as related to curricula, clinical educators, and student success. However, the inclusion of evidence-based models, including learning theory, pedagogical strategy, etc., was minimal in the studies examined herein. Curricular innovations for wellness practice instruction may have been statistically significant although their implementation was not threaded into the program or did not address whole-person wellness needs.\u003c/p\u003e \u003cp\u003eFindings across the studies demonstrated positive and negative experiences impacting student perception, well-being, and subsequently outcomes. Studies most often examined wellness practices by \u0026ldquo;adding\u0026rdquo; to existing structures and schedules,(\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e76\u003c/span\u003e) indicating that changes are content driven with likely siloing, rather than threaded into the overall program philosophy and framework. Adding onto existing infrastructure rather than strategically removing or refining practices may predicate endless content cramming and haphazard approaches, requiring even more reason for theoretical grounding.\u003c/p\u003e \u003cp\u003eWithout purposeful actions, PA programs risk diminishing return on student investment. Siloing of wellness-focused educational content as seen in the included studies could impede the acquisition or future transfer of wellness practice knowledge, skills, attitudes, or behaviors beyond the classroom and into the clinical setting. For instance, literature frequently summates multi-faceted concepts, such as \u0026ldquo;burnout\u0026rdquo; \u0026ndash; comprised of 3 subconstructs: emotional exhaustion, cynicism/depersonalization, reduced self-efficacy \u0026mdash; into one primary term. Respectively, use of a primary term without acknowledgement of its subconstructs, and vice versa, may artificially appear singular. Further, terminology used during interpersonal exchanges (verbal and written) can serve to clarify how populations perceive, understand, identify, and label humanistic experiences in the future. Having robust and accurate characterization of these experiences mitigates the potential for inadvertent oversimplification and consequently, the risk of under-delivering necessary supports to enhance fundamental balance and well-being in academia and clinical practice settings.\u003c/p\u003e \u003cp\u003eConsistently, studies demonstrated efficacy of wellness-based curricular innovations such as debriefing, decentering, and mindfulness techniques.(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan additionalcitationids=\"CR63\" citationid=\"CR60\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e64\u003c/span\u003e) Practice strategies that demonstrated mutual respect and consideration for students\u0026rsquo; time as a valuable resource were well-received and validated the importance of meeting students\u0026rsquo; wellness needs (e.g., time to attend medical appointments).(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan additionalcitationids=\"CR69\" citationid=\"CR66\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e70\u003c/span\u003e) Additionally, fostering program and educational cultures that are predictable yet not rigid, was highly regarded when implemented with appropriate scaffolding, reasonable boundaries, and realistic expectations.(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e69\u003c/span\u003e) PA programs and institutions could build on the above noted successes when designing and delivering wellness curricula.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Student Success as Future Providers\u003c/h2\u003e \u003cp\u003eDespite varied definitions and approaches to assess and foster student success, the undeniable and dominating mandate remains\u0026mdash;advocating the return to the fundamentals of humanism, including into PA education. Prioritizing the needs of a person, as a human first, stands to generate inherent value-adds during the time-bound journey with a \u0026ldquo;student\u0026rdquo; persona. Addressing these concerns can improve variables critical to student success.\u003c/p\u003e \u003cp\u003eThe constructs synthesized from this review (Appendix 1) are not simply abstract concepts. Instead, each can contribute to a student\u0026rsquo;s experience \u0026ndash; positive or negative, functioning as \u0026ldquo;protective\u0026rdquo; or \u0026ldquo;risk\u0026rdquo; factors to mediate outcomes of both success and toward well-being.(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Accreditation standards and PA competencies necessitate instruction for health promotion \u0026ndash; prevention, screening, and maintenance,(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e27\u003c/span\u003e) yet educational practices inadequately address the intangible, or \u0026ldquo;non-somatic\u0026rdquo; facets of negative student experiences and overarching unmet wellness needs, as individuals and as a collective.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e92\u003c/span\u003e) The U.S. approach to health and wellness is characteristic of a disease-driven system with emphasis on symptom management rather than preventive services. However, in the authors\u0026rsquo; opinion, this traditional practice of clinical medicine has been long overdue for modernization and transformation.\u003c/p\u003e \u003cp\u003eWhere institutions have experienced unsynchronized systemic changes over years of scientific and technological expansion, embedding wellness frameworks, such as by NWI, can additionally inform evidence-based practice and education with practice approaches via positive psychology.(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e) Intentional approaches to frame verbal and written language shapes experiences that may create meaningful, positive change, or fuel negative neurobiological pathways.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e) Collectively, such exchanges are micro-opportunities toward evidence-based healing practices such as cognitive restructuring. Healthier exposures and outlooks minimize the potential for unnecessary negativity that may otherwise diminish the quality of an experience and therefore, success toward actualization. Based on the research findings, individual\u0026rsquo;s perception of well-being is catalyzed by: 1) ability to compensate for or cope with dysregulation, 2) the type, frequency, and proportion of wellness dimensions affected by disruptions, and 3) the degree of influences contributing to meaningful increases/decreases in wellness. Therefore, burnout and other negative outcomes pose as an antithesis of health, well-being, or wellness, PA education could build on positive psychology principles to move from health promotion to health protection for students as future HCWs.\u003c/p\u003e \u003cp\u003eThe answer to the health burden of students cannot be addressed solely by adding to existing packed schedules(\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e92\u003c/span\u003e, \u003cspan citationid=\"CR94\" class=\"CitationRef\"\u003e96\u003c/span\u003e, \u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e97\u003c/span\u003e). The perpetuated zeitgeist of the past to \u0026ldquo;try harder\u0026rdquo; in the face of crippling HCW and PCW impairment across the U.S. is unacceptable and frankly, dangerous. Core to the physician assistant (PA) ethical duty(\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e77\u003c/span\u003e) is the charge to advocate as a systems-citizen(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e44\u003c/span\u003e) and leader(\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e74\u003c/span\u003e) within the health care ecosystem, including the workplace, education, and research.(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e78\u003c/span\u003e) As these issues continue to go unaddressed, the U.S.\u0026rsquo;s population health burdens of morbidity and mortality increase while the supply of competent and resilient new graduates poised to thrive long-term as HCWs dwindles. The nationwide HCW pulse is thready and in dire need of a wellness transfusion.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e79\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eMeanwhile, the hyper-fixation on student performance related to board exam outcomes or attrition is an oversimplification of \u0026ldquo;success\u0026rdquo; and inadequately characterizes the underlying problems faced by students. As the research findings support, the educational launchpad can serve as an environment to role model healthful practices in academia and strengthen trainees\u0026rsquo; ability to transfer care skills across settings and above all, use them for self-care. Otherwise, educators may unintentionally assume a parentified role with students, leading to interpersonal shifts such as maladaptive \u0026ldquo;unprofessional behavior.\u0026rdquo; Meanwhile, implicit messaging of \u0026ldquo;do as I say and not as I do\u0026rdquo; in the educational environment is not congruent with learner-centered wellness practices. The barren landscape of emotional intelligence and such dynamics fuels unconscious incompetence, and the prevalence of negative student experiences across PA education speaks volumes to the illusory learner-centered environment. What is developed, including through educator modeling during this precious time, is critical.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e80\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eMuch of PA education focuses on QI practices through self-assessment cycles, benchmark transparency, and practice approaches based on data and trend monitoring.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e) It is possible that conceptualizing such benchmarks could unknowingly create the perception of a false dichotomy; that the threshold is either met or not met, each resulting in various action steps\u0026mdash;often disciplinary in nature\u0026mdash;and with outcomes negatively impacting students.(\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e55\u003c/span\u003e) The outcome does not negate what still occurs and is contributory behind the scenes. The articles reviewed indicate that optimization cannot occur proficiently without a scaffolded, longitudinal design to appropriately map the learner\u0026rsquo;s experience from matriculation through to HCW success. Increasing a learner\u0026rsquo;s potentiation must be propagated with supports whilst impediments are dismantled with through trauma-informed approaches.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e81\u003c/span\u003e) These needs were echoed diffusely across the diverse literature conclusions.\u003c/p\u003e \u003cp\u003eThe Institute for Healthcare Improvement\u0026rsquo;s (IHI) quintuple aim framework(\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e82\u003c/span\u003e) is worthy of inclusion in longitudinal program or curricular mapping for the PCW. Just as an injury leads to sequelae, prolonged systemic misalignment impedes efforts toward optimal health.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e83\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e84\u003c/span\u003e) Educational systems have been short-sighted by not considering students\u0026rsquo; success as future healthcare practitioners\u0026rsquo; success to promote healthful living and care for both patients, and themselves.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e90\u003c/span\u003e) Success is not limited to a board exam and is not a check-box to meet a quota or compliance visit. Reducing the burden of adverse experiences for PA students is possible \u0026ndash; program training, empowering learner voice, fostering emotional intelligence growth, and redesigning schedules to reduce content quantity over quality, to name some strategies aligning with Table\u0026nbsp;1 practice data. What is success if not living purposefully, finding meaning and value across various areas of life, and having the tools to identify imbalance or restore equilibrium to the best of one\u0026rsquo;s ability for self and the community?\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eThe Umbrella Model: An Ecosystem of Student Success and Well-being\u003c/h2\u003e \u003cp\u003eGiven the above critical appraisal of the literature and definition of student success, the authors introduce The Umbrella Model for student success and well-being. This model is intended to reframe our collective understanding and recommend practices to optimize student success across the educational ecosystem (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere are numerous forces contributing to the \u0026lsquo;balance\u0026rsquo; of an educational ecosystem. These forces may be conceptualized as \u0026ldquo;success influencers.\u0026rdquo; Each equal and opposing force has the potential to change (or shape) a student\u0026rsquo;s experience in an instant, cumulatively, or both. These \u0026ldquo;influencers\u0026rdquo; are ever-occurring and in-motion, enhancing or diminishing the quality of an educational experience, and poise students closer to or farther from the desired outcomes. How a student is supported through their well-being and equipped to meet the milestone markers of success are guided by the program leadership practices, curriculum, and personnel.\u003c/p\u003e\n\u003cp\u003eAlthough certain influencers can be forecasted and either prevented or mitigated, exposure to various elements is inevitable and at times unpredictable. However, the goal is not to simply provide an absolute shield for students to absolve or avoid exposure to diminishers; it is instead to scaffold, resource, and equitably support their path to enhance likelihoods of a productive and successful journey onward. It is within the purview of the educational ecosystem to maintain a clear and spacious pathway to prepare, develop, and equip learners to weather the challenges of future clinical practice. There are differing methods used to progress students\u0026rsquo; knowledge, skills, attitudes/behaviors from a \u0026lsquo;novice\u0026rsquo; PCW to a \u0026lsquo;competent\u0026rsquo; HCW contributor. Although the pathway may vary, the overarching goal of the educational experience is transferable across health professions. The centralized shelter and protection afforded along this path is integral to the ecosystem infrastructure of educational experiences to come. Prior to a student leaving the program\u0026apos;s protective covering at graduation, the program confers full \u0026ldquo;entrustment\u0026rdquo; to appropriately deploy and wield their own \u0026ldquo;umbrella\u0026rdquo; into the variable weather of future clinical practice and community betterment.\u003c/p\u003e\n\u003cp\u003eCertain dimensions may, in essence, be larger than other dimensions for a given student. The dimensions - shown as rectangular boxes - have a similar although differing capacity in comparison to one another. These varied capacities represent the relative \u0026ldquo;size\u0026rdquo; of an individual\u0026rsquo;s need(s). How an individual, or student, carries the \u0026ldquo;weight\u0026rdquo; is determined by what is or isn\u0026rsquo;t contributing to meeting their \u0026ldquo;needs capacity.\u0026rdquo; Colloquially, this is reminiscent of the adage query: \u0026ldquo;what do you need to fill \u003cem\u003eyour\u003c/em\u003e cup?\u0026rdquo; Or rather, what are the needs of a student (or individual) and how can they best be met to enhance their resilience longevity toward continued successes and overall well-being?\u003c/p\u003e\n\u003cp\u003eThe distribution of each dimension on the scale will differ according to a student\u0026rsquo;s background, the social drivers, and the pathway maintained by a program\u0026rsquo;s self-assessment processes. How an educational program prepares, develops, and equips learners for success influencers has the potential to enhance or diminish the quality and value of the educational experience. Further, these success influencers and the roles within this educational ecosystem, are drivers (Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eProactive forecasting, intentional efforts, and careful weaving of a longitudinal thread through program practices and organizational culture is vital. Alternatively, unmet needs of these dimensions perpetuate segmented (or siloed) approaches of imbalance and lead to the deterioration of the synergistic forces within the ecosystem. A state of balance is reflective of reality. As humans, there is always a need for replenishment and experiences in life will not be perfect. However, those experiences serve as refinement for growth, expertise, and wisdom. As long as balance is prioritized for students\u0026rsquo; overall well-being, then successes, no matter the size, are inevitable.\u003c/p\u003e\n\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eLimitations\u003c/h2\u003e\n \u003cp\u003eData extraction and analysis proved challenging for several reasons including variable terminology, title brevity, descriptive inconsistencies, and sparse presence of keywords.(\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e) Subconstruct terminology (e.g., burnout) was often used in the title with fewer than half of the studies including the overarching concept of well-being, limiting examination of the primary focus\u0026mdash;wellness or well-being. Analysis was limited by the available data, with incomplete or omitted information denoted in Table\u0026nbsp;1.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eRecommendation for Future Works\u003c/h2\u003e\n \u003cp\u003eThe authors identified a need for unified terminology related to wellness and student success; such work would benefit researchers and students alike. Investigation into the Ph, Sp, Soc, and OWB dimensions is lacking; thus, research focused on these dimensions would provide a more holistic understanding for researchers and education leadership. Finally, implementation and investigation of threaded curricula integrating wellness practices, trauma-informed pedagogy, and learning theory is a much-needed next step.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe need to unite wellness philosophy, definitions, and approaches to wellness practices is evidenced across this article\u0026rsquo;s findings and other prominent research in the health care community. Neglecting to implement wellness practices despite the overwhelming body of research conclusions that we don\u0026rsquo;t need to just try harder, we need to collectively shift the modus operandi of leadership and programs to foster longitudinal person-centered success. It is possible to employ systems-thinking(\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e74\u003c/span\u003e) though joint willingness to part with the comfortable practices of today and integrate the growth-mindset of future is not without its challenges. Across the U.S., the \u0026ldquo;needs assessment\u0026rdquo; has been performed and the research findings are sobering. Sustainability efforts to course-correct from preventable and unnecessary burdens of morbidity and mortality being faced by students and health professions are possible with coordinated efforts like the ones described in the umbrella model.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e80\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e86\u003c/span\u003e) Continuance of willful ignorance otherwise incites doubt for professional and ethical actions. It is time that PA education answers the call for action. Institutions nationally require imminent practice review and alignment, as the future of population well-being depends on it.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eARC-PA - Accreditation Review Commission on Education for the Physician Assistant\u003c/p\u003e\n\u003cp\u003eCBE - Competency-based Education\u003c/p\u003e\n\u003cp\u003eHCW - Healthcare Workforce\u003c/p\u003e\n\u003cp\u003eHPE - Health professions education\u003c/p\u003e\n\u003cp\u003ePA - Physician Assistant/Associate\u003c/p\u003e\n\u003cp\u003ePAEA - PA Education Association\u003c/p\u003e\n\u003cp\u003ePCW - Preclinical Workforce\u003c/p\u003e\n\u003cp\u003eQI - Quality Improvement\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset supporting the conclusions of this article is included within the article and its additional file(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no funding sources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLD collected, analyzed, and interpreted the study data; generated the dataset table and figures; and drafted and revised the manuscript iteratively. EL implemented the search strategy for literature retrieval and provided scholarly feedback. GK reviewed and provided scholarly feedback. CF was a major contributor to the study design, data interpretation, and manuscript revision. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese authors would like to thank the School of Graduate Studies of the University of Maryland-Baltimore (UMB) for their support in this research: Dr. Mary Jo Bondy, DHEd, PA-C, Program Director, Doctor of Medical Science (DMSc); and the PA Leadership \u0026amp; Learning Academy (PALLA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGarvick S, Peacock B, Gillette C. 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IJERPH. 2022 Feb 4;19(3):1780. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health professions, student success, well-being, wellness practices, physician assistant/associate (PA) program, healthcare workforce, preclinical, resilience longevity, competency-based education, quality improvement","lastPublishedDoi":"10.21203/rs.3.rs-6709430/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6709430/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHealth professions students are facing increased impairment, adverse academic experiences, and impeded performance. Despite the well-documented burnout, suicide risk, and other sequelae posing unnecessary challenges for these students, and the health professions community at large, poor quality of life and undesirable outcomes persist. Evidence suggests predisposing factors could be addressed during the student\u0026rsquo;s training period as pre-healthcare workforce (HCWs) or the preclinical workforce (PCW). This scoping review evaluates gaps in the research literature including alignment of terminology, wellness practices, and implications for students as the future HCW. Based on the findings, we propose The Umbrella Model for sustainable student success, well-being, and investment in long-term resilience.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAuthors utilized a JBI scoping review protocol and logic model to investigate the research query. Literature retrieval was led by the research librarian using keywords, Boolean operators, and database-specific terminology. Using a PICOS framework and PRISMA tools, studies were vetted through a phased eligibility screening process according to inclusion/exclusion criteria (PA students, wellness practices, occurred within the U.S., original research). Data extraction occurred systematically and involved categorization of findings based on study sections and constructs. Findings were mapped to the National Wellness Institute (NWI) competency-based models and the PA Core Competencies.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 447 studies were retrieved from searches conducted via database searching (n\u0026thinsp;=\u0026thinsp;439) and handsearching (n\u0026thinsp;=\u0026thinsp;8). After initial screening and full-text review, 25 studies met inclusion criteria. Terminology, wellness practices, and instrumentation varied across the health professions programs. Few studies were anchored in learner-centered theory or pedagogical frameworks. Efficacious practices were often siloed, and no studies addressed all the dimensions of wellness. Unanimous findings support the need for well-being to promote student success.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eUnified terminology, definitions, and implementation of wellness practices are necessary to optimize person-centered success, promote work-life balance, and transform antiquated systems into ecosystems equipped for long-term sustainability.\u003c/p\u003e","manuscriptTitle":"Optimizing Wellness and Student Success. 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